Lawyers start mining the Medicare data for clues to fraud

April 14 | By Terry Baynes

April 14 (Reuters) - Within hours of the U.S. government's
unprecedented release last week of a trove of Medicare billing
data, a small fraternity of lawyers who specialize in
representing whistleblowers in healthcare fraud cases began to
mobilize.

These lawyers earn their living bringing cases on behalf of
employees at drug companies and healthcare providers who believe
their bosses or colleagues may be cheating the federal Medicare
system by bribing doctors to prescribe certain drugs, for
example, or inflating bills.

A whistleblower who prevails gets up to 30 percent of
whatever the government recovers, and 40 percent of that reward
typically goes to the whistleblower's lawyer.

Whistleblower cases can result in huge settlements, such as
the $3 billion GlaxoSmithKline paid in 2012 to resolve
claims that it promoted drugs for unapproved uses and failed to
report certain safety data.

Patrick Burns, co-director of Taxpayers Against Fraud, a
nonprofit advocacy group with around 400 whistleblower lawyers
as members, said that right after the release on Wednesday a
handful of lawyers asked him for help accessing the data, which
is available online. The 2012 data runs for 10 million lines and
shows how many times some 880,000 medical providers billed for a
particular service, how much they charged and whether that
deviated from the national norm.

Burns said he sent the database link to the entire
400-lawyer group, under the heading, "Have Fun!"

By Thursday, Pennsylvania lawyer Marc Raspanti was having a
ball. Raspanti said he spent six hours combing through the data.
He has several Medicare fraud lawsuits pending against
pharmaceutical companies alleging kickbacks to certain doctors.

Raspanti is analyzing the data, he said, to see if doctors
are prescribing an unusually high amount of the pharmaceutical
company's products. If so, he said, that could bolster
allegations that something is amiss.

In the past Raspanti had to rely on his clients' personal
knowledge of any suspect billings, he said, and then had to
subpoena government agencies for the supporting documents.
"Now I have (the data) at my fingertips." He said that has
helped him on some cases, which he declined to identify.

FOLLOWING THE RED FLAGS

The data could also help direct lawyers to additional
targets or potential witnesses in cases they have already filed,
said Reuben Guttman, a Washington, D.C., whistleblower lawyer
who said he jumped into the database soon after it was released.

For example, if a lawyer were representing a pharmaceutical
sales manager accusing his company of paying kickbacks to
certain doctors, the data could point to other providers using
the company's products who could serve as witnesses or be added
as defendants if the billings suggest wrongdoing.

"It could expand the case beyond a certain institution or
provider to multiple institutions or providers," said Chris
Coffin, a Louisiana lawyer who represents whistleblowers.

Other lawyers said the data could produce leads for new
lawsuits. When red flags emerge - a doctor bills Medicare an
unusually high amount for a particular drug, say - lawyers could
investigate what might explain the aberrant figure. That could
turn up a possible fraud.

"You'd have to be able to see that there's (improper)
influence actually being exerted over healthcare decisions,"
said Michael Behn, a Chicago whistleblower lawyer. "But there's
the possibility this data could lead to actual cases."

Consumer and press groups have been seeking the Medicare
physician data since Jimmy Carter was in the White House. In
1979, the American Medical Association and the Florida Medical
Association convinced a judge to bar officials from releasing
the data to protect physicians' privacy. Last May, a judge
lifted the ban.

AMA spokesman Robert Mills declined to comment on the
digging by lawyers and instead referred to the statement on
Wednesday by AMA President Ardis Dee Hoven.

"Releasing the data without context will likely lead to
inaccuracies, misinterpretations, false conclusions and other
unintended consequences," she said.

Indeed, data alone doesn't make a lawsuit. Lawyers still
need a client with inside knowledge of the alleged fraud. But
employees in physicians' offices or healthcare labs who suspect
wrongdoing can now see whether their employers' billings are
out-of-line with the rest of the industry.

And that could seriously stiffen some of their spines.
(Reporting by Terry Baynes; Editing by Ted Botha, Eric Effron
and Prudence Crowther)